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Bhutanese refugees who have been identified for resettlement to the United States receive additional medical assessments (Figure 6). Some assessments occur several months prior to departure and some occur immediately before departure to the US.

Figure 6: Medical assessment of US-Bound Bhutanese refugees

Visa Medical Examination

A visa medical examination is mandatory for all refugees coming to the United States and must be performed according to the CDC’s Technical Instructions for visa medical examinations. The purpose of the medical examination is to identify applicants with inadmissible health-related conditions. These examinations are performed by panel physicians who are selected by Department of State (DOS) consular officials. CDC provides the technical oversight and training for the panel physicians. In Nepal, all panel physicians work for the International Organization for Migration (IOM). Information collected during the refugee visa medical examination is reported to CDC’s Electronic Disease Notification System (EDN) and is available to state health departments where the refugees are resettled.

Unlike immigrant visa applicants, vaccination requirements do not apply to refugees at the time of their initial admission to the United States. However, currently one dose of each of the vaccines in Table 2 is offered to Bhutanese refugees of the appropriate age group during the visa medical examination.

Pre-Departure Medical Screening

In Nepal, a pre-departure medical screening is conducted about three weeks before departure for the United States for refugees previously diagnosed with class B1 TB (TB fully treated using Directly Observed Therapy, or abnormal chest x-ray with negative sputum smears and cultures, or extrapulmonary TB). The screening includes a repeat physical examination with a focus on TB signs and symptoms, chest x-ray, and sputum collection.

Pre-Embarkation Checks

IOM clinicians perform two pre-embarkation checks within 48 hours of the refugee’s departure to the United States to assess fitness for travel and administer presumptive therapy for intestinal parasites (worms). The first pre-embarkation check is conducted in Damak, one day prior to travel from Damak to Kathmandu. To combat intestinal parasites, all refugees aged ≥2 years receive a single 400 mg dose of albendazole (since February 2012) and children aged 12–23 months receive a single 200 mg dose of albendazole. Chronically ill refugees receive a 4-week supply of their prescription medications. The second pre-embarkation check is performed in the Kathmandu transit center one day before departure from Kathmandu for the United States, primarily to ensure that refugees are fit to fly. Both checks also include screening and treatment for head lice infestation, as needed.

Surveillance

Communicable diseases of public health significance (such as TB), especially as relates to safe travel, are identified during active surveillance through all phases of overseas medical processing. This surveillance is designed to identify refugees with conditions that may result in deferred travel or other interventions, if they are transmissible. In addition, when disease outbreaks occur in the camps, IOM coordinates with AMDA-Nepal to identify refugees in the resettlement program who may be affected. Depending on the nature of the disease outbreak, various interventions may then be employed, such as deferral of travel, additional vaccinations, and/or presumptive or directed therapy.

Post-Arrival Medical Screening

Once refugees have arrived in the US, CDC recommends that they receive a post arrival medical screening (domestic medical screening) within 30 days after arrival. The Office of Refugee Resettlement (ORR) reimburses providers for screenings conducted during the first 90 days after arrival. The purpose of these more comprehensive examinations is to identify conditions that may have been missed during visa medical examinations and to serve as an introduction to the US healthcare system. CDC provides guidelines and recommendations and state health departments oversee and administer the domestic medical screenings. Health departments and private physicians conduct the examinations themselves. Health departments determine who conducts the examinations within their jurisdiction. Data from the screenings are collected by most state health departments.